I breathe you in again just to feel youUnderneath my skin, holding on toThe sweet escape is always laced with afamiliar taste of poison~ HalestormIn female patients with borderline personality disorder (BPD), a behavior pattern is sometimes seen in which the woman quickly gets involved with a seemingly charismatic but at base highly narcissistic male. At the beginning of the relationship, it's love at first sight. There is a whirlwind romance in which both partners seemingly have found their soul mates, and love is professed - occasionally with even a hasty marriage proposal, sometimes within just a couple of weeks. The couple spends all their free time together and can not seem to get enough of each other either physically or mentally.Before too long, however, the man reveals his true nature. He usually becomes extremely controlling, hyper-jealous and possessive. He wants to know where the woman is every second, and tries to isolate her from her friends and family. All the while, he may lie about his own whereabouts and compulsively cheat on the woman. Not infrequently, he becomes physically abusive to her. Alternatively, the seemingly exact opposite may happen. Without warning, the man seems to lose interest in her entirely, but nonetheless continues to string the relationship along for a considerable period of time.In many such cases, after the couple finally breaks up, the woman repeats a nearly identical pattern with another man. She never seems to learn from her mistakes, and denies that she has ever seen any red flags that indicate that things might go awry.What on earth is going on in the mind of such a woman? In her new book, author Anna Berry (a pseudonym) does a marvelously detailed, brilliantly written, and entertaining job of describing her experiences with instances of her involvement with three such men. The memoir is an excellent introduction to the inside of the head of someone like her.In another part of the book, she describes an experience in which she sort of toys with a psychiatry resident serving as her therapist, demanding that he help her to get back a guy who has treated her like crap and then dumped her. The therapist persists in gamely confronting her about how obviously ill-advised and self-destructive such a course of action would be, if it were even possible. As described by the author, the resident seems to be following the suggestions of James Masterson, one of the early psychoanalytic pioneers in the treatment of BPD, to confront, confront, and confront some more. Such confrontations are supposed to be done empathically, however, and in this the therapist falls short, at least in the descriptions of the author.At some point he even tells her she is a hopeless case - something a therapist should never say to a patient even for effect. She is often snide and sarcastic to him in therapy, yet she continues to see him and even feels abandoned when he has to move away.The author eventually got herself out of her self destructive lifestyle and then does pretty well for herself. So what is her explanation for her earlier, crazy-sounding behavior? Well, she says it was because she was (and still is) both mentally ill herself, and comes from a crazy family. She at times uses the word delusional to describe herself, and also states categorically that she had brief psychotic episodes - although as I will discuss, from what she describes in her writing, she never once says anything that would clearly illustrate a delusion, hallucination, or any other evidence of psychosis. What she describes so well is something else entirely. So why, even though she does things that seem crazy, does she insist on labeling herself psychotic?Having never evaluated the author myself, I can only guess, although I certainly can speculate and offer a possible hypothesis. More on that later.The confusion about whether the author is mentally ill or just self-destructive arose when I was approached by the publisher to write this review. Initially, it sounded like the book was about the difficulty in growing up in a family with a parent who was chronically and persistently mentally ill, possibly schizophrenic. While having a psychotic parent can certainly create family dysfunction and personality problems in offspring, it also sounded like the author herself was struggling with psychosis, and psychotic illnesses per se are not the main focus of this blog. When I asked them for clarification on this, the answer I got did almost nothing to clearly answer my question.In the book, the patient discusses her own diagnosis, and implies that BPD was the closest thing in the diagnostic manual, the DSM, to what she had. Nothing in the book would cause me to doubt that proposition. She also discusses how she was also diagnosed by different mental health practitioners with a different diagnosis almost every time she saw a different one - clinical depression, bipolar disorder, bipolar II, multiple personality disorder, episodic depression, seasonal affective disorder, dysthymia, cyclothymia, anti-social personality disorder, histrionic personality disorder, schizotypal personality disorder, and post traumatic stress disorder.Her conclusion from having had these different diagnoses was that people just don't fit neatly into the DSM diagnostic boxes. While that is somewhat true, and while it is also true that people can have more than one psychiatric condition (comorbidity), it seems that in her case these labels were applied to her when she in fact did not actually fit the diagnostic criteria at all. She cannot be bipolar if she never had anything resembling a manic episode, or be histrionic when she is primarily an introvert who usually hates to be the center of attention, or have seasonal affective disorder and be depressed at any time of year.The diagnosis of the author's mother is rather obscure in the author's descriptions. Her brother clearly has severe schizophrenia, and in the beginning of the book it sounds as though the mother did too. She clearly had psychotic episodes. At one point she throws a lot of the possessions in the house out because voices are telling her that the objects are dirty and if she doesn't throw them away, everyone in the family will get sick and die. As the book progresses, it eventually becomes clear that the mother's psychotic episodes are episodic and accompanied by her talking non stop and staying up without any sleep for days at a time. Her psychotic episodes would be exacerbated by prescription drug abuse and alcohol - she would often get large quantities of benzodiazepines and other controlled substances from three different free clinics that never communicated with one another. Again, without examining her myself, true bipolar disorder would be the most likely diagnosis if these descriptions are accurate and complete.Clearly growing up in a chaotic household has a bad effect on the author's mental stability, particularly as she was neglected quite a bit. There often was no food in the house. Dad was apparently too busy having sex with his mistresses openly in the house, with the kids there, to go to the grocery store.But has the author ever been delusional? Well maybe, but not by her own descriptions in the book. What she describes as being delusional is really a description of her lying to herself while knowing the truth deep down. A real delusion is believed totally and without any doubt, and is certainly not shared by anyone else like a manipulative boyfriend. This is an essential distinction.In describing her rush towards involvement with one of the problematic men, she says she "could have seen the warning signs a mile away" (p.29). Although she does not explicitly that she did not see them - it sounds like she made a concerted effort not to. On page 74, she writes, " I still didn't have the insight to recognize my destructive relationship patterns, but I can feel the impending doom approaching deep in the pit of my stomach, the way a seasoned sailor can feel approaching storms in his very bones."That clearly sounds like it was not insight into her relationship patterns that was lacking, but rather that she had decided not to think too much about them. Last time I checked, stomachs can't really think.On page 87, she describes red flags going up in her brain, but then shrugging her concerns off. Again, not a psychotic process. She also peppers the book with phrases such as "passive aggressive cry for help and state of denial." Not psychosis.She describes her "voices" as almost psychotic hallucinations, but they sound a lot more like the "tapes" we all have running in our heads left over from childhood that tell us what to do and not to do. They are not described as completely external voices like the ones we all hear every day coming from other real people. The hallucinations of psychosis are more like real external voices than inner thoughts.The first clue that she had never been psychotic was actually a beautiful description of a person with BPD's inner experience - way back on page 5: "...the day-to-day torture of having to create inner and outer selves simultaneously, and maintaining both convincingly...perfect real world training for a professional actor."So why does she keep telling herself how mentally ill she is? Well, one possibility is that, coming from a family where mental illness is sort of the norm, these thoughts provide her with a sense of belonging and familiarity. Those are powerful needs for most people. Again and again, she uses the same words to describe both herself and her mother, as if their psychiatric experiences were actually far more similar than they really were.But of course she would be conflicted about thinking herself to be crazy, because, deep down, nobody really wants to be or thought of by others in that way. The author often lived in fear that someone would find out how crazy she was - before demonstrating it to them in spades.On page 200, she indicates that one of the most important lessons she learned from her psychotherapy was "I am not my parents." More accurately, she probably learned she did not have to be like them. Her mother and brother would never have recovered the same way she did with just the treatment she eventually received that was helpful to her.